Prevalence and characteristics of multiple psychiatric disorders in cardiac rehabilitation patients

Global Prevalence of Anxiety in Adult Cardiology Outpatients: A Systematic Review and Meta-analysis

Anxiety and anxiety disorders are associated with adverse cardiovascular outcomes, and reduced quality of life. Despite this, no comprehensive study on the global prevalence of anxiety symptoms and disorders among adult cardiology outpatients exists. This systematic review and meta-analysis aims to provide cardiologists with a precise estimate of the prevalence of anxiety in their outpatient clinics. PubMed, Embase, Cochrane and PsycINFO databases and Google Scholar were searched from database inception to January 23, 2023. Data characteristics were extracted independently by 2 investigators. Ninety-three studies, n = 36,687 participants across 31 countries, were included. Global prevalence of anxiety symptoms/disorders was 28.9% (95%CI 25.7-32.4; 8927/36, 687; I2 = 97.33; n = 93). The highest rates were found in patients presenting with hypertension, 43.6%. Subgroup analyses revealed higher prevalence estimates when using self-report screening compared to gold-standard diagnostic interview. When using diagnostic interview, the highest rates were reported in outpatients with undifferentiated chest pain/palpitations, 19·0%. Panic disorder was the most frequent diagnosis 15.3%, and rates were significantly higher in patients with undifferentiated chest pain/palpitations compared to ischemic heart disease. Higher rates of anxiety were found in studies of outpatients from developing countries, and female outpatients tended to have higher rates compared to males. Anxiety occurred frequently among cardiology outpatients and at a higher rate than estimated in the general population. Given the impact anxiety has on patient outcomes, it is important that effective identification and management strategies be developed to support cardiologists in identifying and treating these conditions in their clinics.

Translation, Cultural Adaptation, and Validation of a Korean Version of the Information Needs in Cardiac Rehabilitation Scale

OBJECTIVE

: To translate and culturally adapt the Information Needs in Cardiac Rehabilitation (INCR) questionnaire into Korean and perform psychometric validation.

METHODS

: The original English version of the INCR, in which patients are asked to rate the importance of 55 topics, was translated into Korean (INCR-K) and culturally adapted. The INCR-K was tested on 101 cardiac rehabilitation (CR) participants at Kangwon National University Hospital and Seoul National University Bundang Hospital in Korea. Structural validity was assessed using principal component analysis, and Cronbach's alpha of the areas was computed. Criterion validity was assessed by comparing information needs according to CR duration and knowledge sufficiency according to receipt of education. Half of the participants were randomly selected for 1 month of re-testing to assess their responsiveness.

RESULTS

: Following cognitive debriefing, the number of items was reduced to 41 and ratings were added to assess participants' sufficient knowledge of each item. The INCR-K structure comprised eight areas, each with sufficient internal consistency (Cronbach's alpha>0.7). Criterion validity was supported by significant differences in mean INCR-K scores based on CR duration and knowledge sufficiency ratings according to receipt of education (p<0.05). Information needs and knowledge sufficiency ratings increased after 1 month of CR, thus supporting responsiveness (p<0.05).

CONCLUSION

: The INCR-K demonstrated adequate face, content, cross-cultural, structural, and criterion validities, internal consistency, and responsiveness. Information needs changed with CR, such that multiple assessments of information needs may be warranted as rehabilitation progresses to facilitate patient-centered education.

Prevalence of post-traumatic stress and tests of metacognition as a PTSD risk marker in patients with coronary heart disease and elevated HADS scores: analysis of data from the PATHWAY RCT's in UK cardiac rehabilitation

Introduction

Anxiety and depression in coronary heart disease (CHD) are associated with poorer health outcomes, greater healthcare use and reduced quality of life. Post-traumatic stress symptoms may be a particular concern as they are associated with increased mortality at follow-up. We examined prevalence of PTSD in patients with elevated anxiety/depression scores referred for cardiac rehabilitation (CR) across seven NHS sites in North-West England. We tested a possible mechanism (metacognition) linking CHD to PTSD symptom severity as implicated in the metacognitive model.

Methods

Data was collected at baseline as part of the NIHR funded PATHWAY trial of metacognitive therapy for anxiety and depression in CHD. Patients (n = 572) with at least mild symptoms of anxiety and depression under routine screening (assessed with the Hospital Anxiety and Depression Scale) and attending CR were eligible for the study. A battery of questionnaires, including assessment of demographic variables, PTSD symptoms (using the IES-R) and metacognitive beliefs was administered prior to random allocation and intervention delivery.

Results

Rates of PTSD were high, with 48% of patients meeting threshold for PTSD and a further 15% partial PTSD. All five metacognition subscales were positively associated with PTSD vs. no PTSD, with beliefs about the uncontrollability and danger of worry and beliefs about need to control thoughts being most strongly related. For every unit increase in uncontrollability and danger metacognitions the odds of being in the PTSD group increased 30%, whilst the odds of partial PTSD increased 16%. Stepwise regression analysis using the metacognitive subscales along with demographic and health-related covariates found that uncontrollability/danger and need for control metacognitions explained unique variation in PTSD symptom severity, with unique contributions also for age, sex, and number of comorbidities.

Conclusion

PTSD symptoms appeared highly prevalent in the current CR sample. Metacognitive beliefs were individually associated with symptom severity with the strongest positive relationship observed for beliefs about uncontrollability and dangerousness of worry, followed by need to control thoughts. The results highlight the importance in assessing PTSD in CR patients and add support to implementing metacognitive therapy in CHD to target particular metacognition risk factors in anxiety, depression and PTSD.

Evaluating the Feasibility and Efficacy of A Novel CBTi/SMT Treatment Protocol for Cardiac Rehab Patients: A Non-Randomized Pilot Trial

INTRODUCTION

Cardiac patients and those with chronic medical conditions often suffer from comorbidities such as insomnia and mood disorders. Previous treatment protocols have focused on resolving symptoms of anxiety and depression in this population using Stress Management Training (SMT). However, these treatments have neglected the importance of sleep problems in these patients. This pilot trial sought to address this by examining the feasibility of a novel CBTi/SMT treatment protocol.

METHODS

42 participants attending a Cardiac Rehab (CR) exercise program registered in this 7-week non-randomized pilot trial. The primary objective of the pilot trial was to determine the feasibility of the protocol for retention and adherence rates. Secondarily, the authors sought to examine the potential efficacy of the program in terms of treating insomnia, depression, anxiety, emotion dysregulation, and arousal.

RESULTS

29 participants attended at least 1 class, with 21 participants completing the program. The average attendance for the program completers was 6 out of 7 classes (SD = 0.8) with four days of practice each week (SD = 1.6) for 33 minutes daily (SD = 16.8). Moreover, the number of participants meeting clinical threshold for insomnia, anxiety, and/or depression was significantly reduced at post-treatment and follow-up. Similarly, raw scores on the relevant scales were significantly reduced at both timepoints.

CONCLUSION

This pilot trial provided preliminary evidence for the feasibility and efficacy of targeting sleep improvement with a combined CBTi/SMT protocol. This provides the groundwork for future RCTs to establish the effectiveness of targeting insomnia in a range of medical populations.

Effectiveness of e-Health cardiac rehabilitation program on quality of life associated with symptoms of anxiety and depression in moderate-risk patients

Exploring new models of medical care requires evaluating the impact of new care strategies not only on physiological parameters but also on the quality of life of the patient. On the other hand the presence of anxiety together with depression requires further consideration when planning appropriate management strategies. The aim of this study was to examine the effectiveness of a home-based cardiac rehabilitation program incorporating an e-Health technology on health-related quality of life associated with symptoms of anxiety and depression in moderate-risk patients. A multicenter, randomized controlled clinical trial was designed to compare a traditional hospital based cardiac rehabilitation program (n = 38, 35 male) with a mixed home surveillance program where patients exercised at home with a remote electrocardiographic monitoring device (n = 33, 31 male). The Short Form-36 (SF-36) Health Survey and the Goldberg questionnaire were used to evaluate quality of life and the presence of symptoms of anxiety and depression respectively. The results of this study show that the type of cardiac rehabilitation program did not influence the improvement in quality of life (p = 0.854), but the presence of symptoms of anxiety and depression did (p = 0.001). Although both programs achieved a decrease in anxiety and depression symptoms and improved functional capacity (p ≤ 0.001), a significant interaction effect was found between the group with or without anxiety and depression symptoms and the type of program in the bodily pain dimension (p = 0.021). Trial registration: Retrospectively registered NCT02796404 (10/06/2016) in clinialtrials.gov.

Impact of cognitive behavioral therapy on depression symptoms after transcatheter aortic valve replacement: A randomized controlled trial

BACKGROUND

Depression is a significant concern after cardiac surgery and has not been studied in patients undergoing transcatheter aortic valve replacement (TAVR). We sought to examine the prevalence of pre-procedure depression and anxiety symptoms and explore whether brief bedside cognitive behavioral therapy (CBT) could prevent post-TAVR psychological distress.

METHODS

We prospectively recruited consecutive TAVR patients and randomized them to receive brief CBT or treatment as usual (TAU) during their hospitalization. Multi-level regression techniques were used to evaluate changes by treatment arm in depression, anxiety, and quality of life from baseline to 1 month post-TAVR adjusted for sex, race, DM, CHF, MMSE, and STS score.

RESULTS

One hundred and forty six participants were randomized. The mean age was 82 years, and 43% were female. Self-reported depression and anxiety scores meeting cutoffs for clinical level distress were 24.6% and 23.2% respectively. Both TAU and CBT groups had comparable improvements in depressive symptoms at 1-month (31% reduction for TAU and 35% reduction for CBT, p = .83). Similarly, both TAU and CBT groups had comparable improvements in anxiety symptoms at 1-month (8% reduction for TAU and 11% reduction for CBT, p = .1). Quality of life scores also improved and were not significantly different between the two groups.

CONCLUSIONS

Pre-procedure depression and anxiety may be common among patients undergoing TAVR. However, TAVR patients show spontaneous improvement in depression and anxiety scores at 1-month follow up, regardless of brief CBT. Further research is needed to determine whether more tailored CBT interventions may improve psychological and medical outcomes.

Identifying the Internalizing Disorder Clusters Among Recently Hospitalized Cardiovascular Disease Patients: A Receiver Operating Characteristics Study

Depression and anxiety disorders are common among cardiovascular disease (CVD) populations, leading several cardiology societies to recommend routine screening to streamline psychological interventions. However, it remains poorly understood whether routine screening in CVD populations identifies the broader groups of disorders that cluster together within individuals, known as anxious-misery and fear. This study examines the screening utility of four anxiety and depression questionnaires to identify the two internalizing disorder clusters; anxious-misery and fear. Patients with a recent hospital admission for CVD (n = 85, 69.4% males) underwent a structured clinical interview with the MINI International Neuropsychiatric Interview. The participants also completed the Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder (GAD-7) scale, Overall Anxiety Severity Impairment Scale (OASIS), and the stress subscale of the Depression Anxiety Stress Scale (DASS). The PHQ-9 and the GAD-7 yielded appropriate screening properties to detect three different iterations of the anxious-misery cluster (sensitivity >80.95% and specificity >82.81%). The GAD-7 was the only instrument to display favorable screening properties to detect a fear cluster omitting post-traumatic stress disorder (PTSD) but including obsessive-compulsive disorder (OCD; sensitivity 81.25%, specificity 76.81%). These findings indicate that the PHQ-9 and GAD-7 could be implemented to reliably screen for anxious-misery disorders among CVD in-patients, however, the receiver operating characteristics (ROC) to detect fear disorders were contingent on the placement of PTSD and OCD within clusters. The findings are discussed in relation to routine screening guidelines in CVD populations and contemporary understandings of the internalizing disorders.

Promotion of Home-Based Exercise Training as Secondary Prevention of Coronary Heart Disease: A PILOT WEB-BASED INTERVENTION

BACKGROUND

Although cardiac rehabilitation (CR) is cost- effective in improving the health of patients with coronary heart disease (CHD), less than half of eligible CHD patients attend a CR program. Innovative web-based technologies might improve CR delivery and utilization. We assessed the feasibility and impact on functional capacity and secondary prevention targets of a long-term web-monitored exercise-based CR maintenance program.

METHODS

Low- to moderate-risk CHD patients were recruited at discharge from inpatient CR after a coronary event or revascularization. We developed an interactive web-based platform for secure home individual access control, monitoring, and validation of exercise training. Of 86 eligible patients, 26 consented to participate in the study intervention (IG). Using a quasi-experimental design, we recruited in parallel 27 eligible patients, unavailable for regular web monitoring, who consented to a follow-up visit as usual care (UC).

RESULTS

Among IG, active daily data transmission was 100% during month 1, 88% at month 3, and 81% at 6 months, with sustained improvement in self-reported physical activity beginning with the first week after discharge from inpatient CR (2467 [1854-3554] MET-min/wk) to month 3 (3411 [1981-5347] MET-min/wk, P = .019). Both groups showed favorable changes over time in lipid profile, ventricular function, distance walked in 6 min, and quality of life. At 6 mo, IG achieved a significantly higher proportion of cardiovascular risk factor targets than UC (75 ± 20% vs 59 ± 30%, P = .029).

CONCLUSIONS

Our web-based home CR maintenance program was feasible, well-accepted, and effective in improving physical activity during 6 mo and achieved higher overall adherence to cardiovascular risk targets than UC.

Clinical and Subclinical Distress, Quality of Life, and Psychological Well-Being after Cardiac Rehabilitation

BACKGROUND

The literature has outlined positive effects of cardiac rehabilitation (CR) on clinical psychological distress (DSM depression and anxiety) and quality of life (QoL). In cardiac settings, subclinical distress (subthreshold depressive and anxious symptomatology) and psychological well-being also showed relevant clinical implications. This research explored these psychological variables, their changes over time and cardiac course of CR patients.

METHODS

Clinical and subclinical distress, QoL, and psychological well-being were assessed in 108 consecutive patients undergoing CR, at baseline and up to 12 months after the program's completion.

RESULTS

Of all patients, 25.9 per cent showed high distress with a DSM diagnosis, 31.5 per cent high distress without a DSM diagnosis, and 42.6 per cent low distress. Comparing these subgroups, worse QoL and psychological well-being were significantly linked not only to clinical but also to subclinical distress. After CR completion, a significant reduction in DSM diagnoses was observed, whereas there were no positive effects on subclinical distress, QoL, and well-being, or when they initially occurred, they were not long lasting. Moreover, only the subgroup with high distress without a DSM diagnosis was at greater risk for adverse cardiac outcomes, showing worse scores on items of contentment.

CONCLUSIONS

These findings confirm data on clinical distress reduction after CR completion. However, a large amount of relevant subclinical distress remains and predicts adverse cardiac events.

Community health service center-based cardiac rehabilitation in patients with coronary heart disease: a prospective study

BACKGROUND

Despite considerable efforts to encourage participation, even in some developed countries, proportion of patients participating in institution-based cardiac rehabilitation (CR) programs remained sub-optimal. The present study was designed to investigate the acceptability of community health service center (CHSC)-based Cardiac Rehabilitation (CR), and examine its effectiveness in terms of changes in quality of life (QOL), psychological state and exercise capacity.

METHODS

A consecutive series of eligible patients was recruited from the health registration system of two CHSCs in Shijiazhuang, Hebei, China. Patients in intervention site were provided with CR (CR-group) while patients in non-intervention site were offered the usual care (UC-group). Data regarding health-related QOL (HRQoL), psychological state and exercise capacity (6-min walk test = 6MWT) were collected and compared at baseline and at 6 months post-intervention.

RESULTS

Among invited patients eligible for CR program, 65.3% participated, while 5.3% of the participants dropped out during follow-up. Patients in CR-group showed significant decrease in the scores for anxiety and depression as per the Hospital Anxiety and Depression Scale (HADS), along with marked increases in the Short-Form Health Survey (SF-12)-based Physical (PCS) and Mental Component Summary (MCS) scores. Moreover, the measurement of 6MWT showed a significant increase of 57.42 m walking distance among CR patients in contrast with a slight increase among UC patients.

CONCLUSIONS

Given the high participation and low withdrawal along with considerable improvements in HRQoL, psychological state and exercise capacity, CHSC was likely to be the optimal setting for implementing CR for patients with CHD in China.

TRIAL REGISTRATION

ChiCTR-TRC- 12002500 . Registered 16 September 2012.

Psychosocial aspects in cardiac rehabilitation: From theory to practice. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation of the European Society of Cardiology

A large body of empirical research shows that psychosocial risk factors (PSRFs) such as low socio-economic status, social isolation, stress, type-D personality, depression and anxiety increase the risk of incident coronary heart disease (CHD) and also contribute to poorer health-related quality of life (HRQoL) and prognosis in patients with established CHD. PSRFs may also act as barriers to lifestyle changes and treatment adherence and may moderate the effects of cardiac rehabilitation (CR). Furthermore, there appears to be a bidirectional interaction between PSRFs and the cardiovascular system. Stress, anxiety and depression affect the cardiovascular system through immune, neuroendocrine and behavioural pathways. In turn, CHD and its associated treatments may lead to distress in patients, including anxiety and depression. In clinical practice, PSRFs can be assessed with single-item screening questions, standardised questionnaires, or structured clinical interviews. Psychotherapy and medication can be considered to alleviate any PSRF-related symptoms and to enhance HRQoL, but the evidence for a definite beneficial effect on cardiac endpoints is inconclusive. A multimodal behavioural intervention, integrating counselling for PSRFs and coping with illness should be included within comprehensive CR. Patients with clinically significant symptoms of distress should be referred for psychological counselling or psychologically focused interventions and/or psychopharmacological treatment. To conclude, the success of CR may critically depend on the interdependence of the body and mind and this interaction needs to be reflected through the assessment and management of PSRFs in line with robust scientific evidence, by trained staff, integrated within the core CR team.

The real world mental health needs of heart failure patients are not reflected by the depression randomized controlled trial evidence

INTRODUCTION

International depression screening guidelines in heart failure (HF) are partly based on depression treatment efficacy from randomized controlled trials (RCTs). Our aim was to test the external validity of depression RCT criteria in a sample of real-world HF patients.

METHODS

HF patients admitted to 3 hospitals in South Australia were referred to a HF psychologist if not already receiving current psychiatric management by psychologist or psychiatrist elsewhere. Screening and referral protocol consisted of the following; (a). Patient Health Questionnaire ≥ 10; (b). Generalized Anxiety Disorder Questionnaire ≥ 7); (c). positive response to 1 item panic attack screener; (d). evidence of suicidality. Patients were evaluated against the most common RCT exclusion criteria personality disorder, high suicide risk, cognitive impairment, psychosis, alcohol or substance abuse or dependency, bi-polar depression.

RESULTS

Total 81 HF patients were referred from 404 HF admissions, and 73 were assessed (age 60.6 ± 13.4, 47.9% female). Nearly half (47%) met at least 1 RCT exclusion criterion, most commonly personality disorder (28.5%), alcohol/substance abuse (17.8%) and high suicide risk (11.0%). RCT ineligibility criteria was more frequent among patients with major depression (76.5% vs. 46.2%, p<.01) and dysthymia (26.5% vs. 7.7%, p = .03) but not significantly associated with anxiety disorders. RCT ineligible patients reported greater severity of depression (M = 16.6 ± 5.0 vs. M = 12.9 ± 7.2, p = .02) and were higher consumers of HF psychotherapy services (M = 11.5 ± 4.7 vs. M = 8.5 ± 4.8, p = .01).

CONCLUSION

In this real-world sample comparable in size to recent RCT intervention arms, patients with depression disorders presented with complex psychiatric needs including comorbid personality disorders, alcohol/substance use and suicide risk. These findings suggest external validity of depression screening and RCTs could serve as a basis for level A guideline recommendations in cardiovascular diseases.

Effects of a comprehensive cardiac rehabilitation program on quality of life in patients with coronary artery disease

BACKGROUND

Health-related quality of life is an important factor to evaluate effects of different interventions in cardiovascular diseases. Improvement in quality of life (QOL) is an important goal for individuals participating in cardiac rehabilitation (CR) programs. The purpose of this study was to assess the impact of comprehensive CR on QOL in patients with cardiovascular disease (CAD).

METHODS

In this quasi-experimental before-after study, the files of 100 patients with CAD who were referred to rehabilitation department of Isfahan Cardiovascular Research Institute were studied using a consecutive sampling method. Data collection was performed from the patient's files including their demographics, ejection fraction, functional capacity, and resting heart rate. All patients participated in a comprehensive CR program and completed the validated questionnaire Short-Form 36 Health Status Survey (SF-36), before and after CR program. Data was analyzed based on sex and age groups (≥ 65 and < 65 years) using independent t-test and paired t-test (to compare variables between groups and before and after CR, respectively).

RESULTS

After CR, scores of all physical domains of the SF-36 including physical function (PF), physical limitation (PL), body pain (BP) and vitality (V) in addition to general health (GH) were significantly improved in all patients (P < 0.05) compared to the baseline. Patients with age < 65 years had greater improvements in mental health (MH) and social function (SF) than patients with age ≥ 65 years (P < 0.05). Women had greater improvement in PF, V and MH compared to men (P < 0.05).

CONCLUSION

These results indicated that CR can improve QOL in cardiac patients especially in women. Elderly patients get benefit the same as other patients in physical domains.

Prevalence of Chest Pain, Depression, Somatization, Anxiety, Global Distress, and Substance Use among Cardiac and Pulmonary Rehabilitation Patients

Psychosocial factors of cardiovascular disease receive a preponderance of attention. Little attention is paid to psychosocial factors of pulmonary disease. This paper sought to describe psychosocial characteristics and to identify differences between cardiac and pulmonary patients entering a phase II rehabilitation program. Parametric and nonparametric analyses were conducted to examine scores on the Brief Symptom Inventory-18 (BSI-18) and the CAGE-D, administered at entry as standard clinical care. Participants were 163 cardiac and 63 pulmonary patients. Scores on the BSI-18 “chest pain” item indicated that more cardiac patients report chest pain than pulmonary patients. Among all subjects, chest pain ratings were positively related to anxiety, depression, and global distress. There were equivocal proportions of anxiety and somatization in patient groups. Pulmonary patients were more likely to endorse clinically significant levels of depression and global psychological distress than cardiac patients. Cardiac patients were significantly more likely to screen positively on the CAGE-D than pulmonary patients. Findings show a relationship between symptoms of chest pain and psychological distress. Despite equivalent proportions of anxiety and somatization between groups, a greater proportion of pulmonary patients reported symptoms of depression and global psychological distress, while more cardiac patients reported chest pain. Further research is needed to examine this paradigm.

Quality of life in medically ill persons with comorbid mental disorders: a systematic review and meta-analysis

BACKGROUND

This systematic review aims to investigate the association between comorbid mental disorders and quality of life (QoL) in patients with chronic medical diseases.

METHODS

Studies investigating adults with diabetes mellitus, coronary artery disease, asthma, chronic back pain and colorectal cancer were included. Two reviewers independently extracted data and assessed methodological criteria. Effect sizes for QoL scores were analyzed in random-effects meta-analyses. Subgroup and sensitivity analyses were conducted.

RESULTS

The database search identified 7,291 references and 65 primary studies were included. Medically ill persons with comorbid mental disorders showed a significantly decreased overall (d = -1.10; 95% CI = -1.34 to -0.86), physical (d = -0.64; 95% CI = -0.74 to -0.53) and psychosocial (d = -1.18; 95% CI = -1.42 to -0.95) QoL compared to persons without mental disorders. Subgroup analyses did not reveal significant differences between the examined medical diseases or mental disorders.

CONCLUSION

The review provides evidence of a substantially reduced psychosocial and physical QoL in medically ill patients with comorbid mental disorders. This patient-reported outcome highlights the importance of recognizing and treating comorbid mental disorders in the medically ill.

Fourth revolution in psychiatry - Addressing comorbidity with chronic physical disorders

The moral treatment of mental patients, Electro Convulsive therapy (ECT), and Psychotropic medications constitute the first, second, and third revolution in psychiatry, respectively. Addressing comorbidities of mental illnesses with chronic physical illnesses will be the fourth revolution in psychiatry. Mind and body are inseparable; there is a bidirectional relationship between psyche and soma, each influencing the other. Plausible biochemical explanations are appearing at an astonishing rate. Psychiatric comorbidity with many chronic physical disorders has remained neglected. Such comorbidity with cardiac, respiratory, Gastrointestinal, endocrinal, and neurological disorders, trauma, and other conditions like HIV and so on, needs to be addressed too. Evidence base of prevalence and causal relationship of psychiatric comorbidities in these disorders has been highlighted and strategies to meet the challenge of comorbidity have been indicated.